Robotic Surgery in Inflammatory Bowel Disease

Assessing robotic-assisted surgery versus open approach in penetrating Crohn's disease: advantages and outcomes in ileocolic resection

INTRODUCTION

Penetrating Crohn's disease (CD) often necessitates surgical intervention, with the open approach traditionally favored. Robotic-assisted surgery offers potential benefits but remains understudied in this complex patient population. Additionally, the lack of standardized surgical complexity scoring in CD hinders research and comparisons.

METHODS

We retrospectively analyzed adult patients with penetrating CD who underwent either robotic-assisted ileocolic resection (RICR) or open ileocolic resection (OICR) at our institution from January 2007 to December 2021. We assessed endpoints, including length of stay, complications, readmissions, reoperations, and other perioperative outcomes.

RESULTS

RICR demonstrated safety outcomes comparable to OICR. Importantly, RICR patients experienced significantly reduced estimated blood loss (p < 0.0001), shorter hospital stays (median 4.5 days versus 6.9 days; p = 0.01), lower surgical site infection rates (0% versus 15.4%; p = 0.01), and decreased 30-day readmission rates (0% versus 15.4%; p = 0.01). Linear regression analysis revealed the need for additional strictureplasties (coefficient: 84.8; p = 0.008), colonic resections (coefficient: 41.7; p = 0.008), and estimated blood loss (coefficient: 0.07; p = 0.002) independently correlated with longer operative times).

CONCLUSION

Robotic-assisted surgery appears to be a safe and potentially beneficial alternative for the surgical management of penetrating CD, offering advantages in perioperative outcomes reducing length of stay, blood loss, surgical site infection rates, and readmission rates. Further validation with larger cohorts is warranted.

Implementation of a robotic surgical practice in inflammatory bowel disease

Robotics adoption has increased in colorectal surgery. While there are well-established advantages and standardised techniques for cancer patients, the use of robotic surgery in inflammatory bowel disease (IBD) has not been studied yet. To evaluate the feasibility and safety of robotic surgery for IBD patients. Prospectively data in IBD patients having robotic resection at Guy's and St Thomas' hospital. All resections performed by a single colorectal surgeon specialised in IBD, utilising DaVinci platform. July 2021 to January 2023, 59 robotic IBD cases performed, 14 ulcerative colitis (UC) and 45 Crohn's disease (CD). Average age; CD patients 35, UC 33 years. Average Body mass index (BMI); 23 for CD and 26.9 for UC patients. In total, we performed 31 ileo-caecal resections (ICR) with primary anastomosis (18 Kono-S anastomosis, 6 mechanical anastomosis and 7 ileo-colostomy), of those 4 had multivisceral resections (large bowel, bladder, ovary). Furthermore, 14 subtotal colectomy (1 emergency), 8 proctectomy, 3 panproctocolectomy and 3 ileoanal J pouch. 18 of the 45 patients (45.0%) with Crohn's disease had ongoing fistulating disease to other parts of the GI tract (small or large bowel). ICR were performed using different three ports position, depending on the anatomy established prior to surgery with magnetic resonance images (MRI). One patient had conversion to open due to anaesthetic problems and one patient required re-operation to refashion stoma. 98.0% cases completed robotically. Median Length of hospital stay (LOS) was 7 days for CD and 7 for UC cases, including LOS in patients on pre-operative parenteral nutrition. Robotic colorectal techniques can be safely used for patients with IBD, even with fistulating disease. Future research and collaborations are necessary to standardize technique within institutions.

National trends and feasibility of a robotic surgical approach in the management of patients with inflammatory bowel disease

BACKGROUND

Research on the utilization of robotic surgical approaches in the management of inflammatory bowel disease (IBD) is limited. The aims of this study were to identify temporal trends in robotic utilization and compare the safety of a robotic to laparoscopic operative approach in patients with IBD.

METHODS

Patients who underwent minimally invasive surgery (MIS) for IBD were identified using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2013-2021). Temporal trends of robotic utilization were assessed from 2013 to 2021. Primary (30-day overall and serious morbidity) and secondary (unplanned conversion to open) outcomes were assessed between 2019 and 2021, when robotic utilization was highest. Multivariable logistic regression was performed.

RESULTS

The use of a robotic approach for colectomies and proctectomies increased significantly between 2013 and 2021 (p < 0.001), regardless of disease type. A total of 6016 patients underwent MIS for IBD between 2019 and 2021. 2234 (37%) patients had surgery for UC [robotic 430 (19.3%), lap 1804 (80%)] and 3782 (63%) had surgery for CD [robotic 500 (13.2%), lap 3282 (86.8%)]. For patients with UC, there was no difference in rates of overall morbidity (22.6% vs. 20.7%, p = 0.39), serious morbidity (11.4% vs. 12.3%, p = 0.60) or conversion to open (1.5% vs. 2.1%, p = 0.38) between the laparoscopic and robotic approaches, respectively. There was no difference in overall morbidity between the two groups in patients with CD (lap 14.0% vs robotic 16.4%, p = 0.15), however the robotic group exhibited higher rates of serious morbidity (7.3% vs. 11.2%, p < 0.01), shorter LOS (3 vs. 4 days, p < 0.001) and lower rates of conversion to an open procedure (3.8% vs. 1.6%, p = 0.02). Adjusted analysis showed similar results.

CONCLUSION

The use of the robotic platform in the surgical management of IBD is increasing and is not associated with an increase in 30-day overall morbidity compared to a laparoscopic approach.

Selenized Polymer-Lipid Hybrid Nanoparticles for Oral Delivery of Tripterine with Ameliorative Oral Anti-Enteritis Activity and Bioavailability

The oral delivery of insoluble and enterotoxic drugs has been largely plagued by gastrointestinal irritation, side effects, and limited bioavailability. Tripterine (Tri) ranks as the hotspot of anti-inflammatory research other than inferior water-solubility and biocompatibility. This study was intended to develop selenized polymer-lipid hybrid nanoparticles loading Tri (Se@Tri-PLNs) for enteritis intervention by improving its cellular uptake and bioavailability. Se@Tri-PLNs were fabricated by a solvent diffusion-in situ reduction technique and characterized by particle size, ζ potential, morphology, and entrapment efficiency (EE). The cytotoxicity, cellular uptake, oral pharmacokinetics, and in vivo anti-inflammatory effect were evaluated. The resultant Se@Tri-PLNs were 123 nm around in particle size, with a PDI of 0.183, ζ potential of −29.70 mV, and EE of 98.95%. Se@Tri-PLNs exhibited retardant drug release and better stability in the digestive fluids compared with the unmodified counterpart (Tri-PLNs). Moreover, Se@Tri-PLNs manifested higher cellular uptake in Caco-2 cells as evidenced by flow cytometry and confocal microscopy. The oral bioavailability of Tri-PLNs and Se@Tri-PLNs was up to 280% and 397% relative to Tri suspensions, respectively. Furthermore, Se@Tri-PLNs demonstrated more potent in vivo anti-enteritis activity, which resulted in a marked resolution of ulcerative colitis. Polymer-lipid hybrid nanoparticles (PLNs) enabled drug supersaturation in the gut and the sustained release of Tri to facilitate absorption, while selenium surface engineering reinforced the formulation performance and in vivo anti-inflammatory efficacy. The present work provides a proof-of-concept for the combined therapy of inflammatory bowel disease (IBD) using phytomedicine and Se in an integrated nanosystem. Selenized PLNs loading anti-inflammatory phytomedicine may be valuable for the treatment of intractable inflammatory diseases.

An early experience in robotic ileoanal pouch surgery with robotic intracorporeal single-stapled anastomosis (RiSSA) at a tertiary referral centre

AIM

A robotic approach to ileal pouch-anal anastomosis (IPAA) surgery offers advantages over other approaches in terms of precision, improved access to the pelvis and less muscular fatigue for the surgeon. The integrity of the anastomosis is also fundamental to successful IPAA surgery. The robotic platform can permit intracorporeal suturing deep within the pelvis to create a single-stapled, double purse-string anastomosis, which may reduce the risk of anastomotic complications. This study describes the safety and early outcomes of robotic intracorporeal single-stapled anastomosis (RiSSA) amongst patients operated consecutively at a tertiary centre immediately before and following the pandemic.

METHOD

A retrospective study of prospectively collected data analysing the outcome of patients undergoing robotic IPAA between 2019 and 2022 was conducted. All procedures were performed with the da Vinci Xi Surgical System (with a hand-assisted suprapubic incision to fashion the pouch). All pouch-anal anastomoses were performed using a double purse-string, single-stapled (RiSSA) method. Demographic, clinical and outcome data were collected.

RESULTS

Twenty consecutive patients (nine with ulcerative colitis and 11 with familial adenomatous polyposis) were included with a median age of 25 years (range 16-52); 18 had American Society of Anesthesiologists classification II, and mean body mass index was 24 kg/m² (range 18.1-34.3). Nine patients (eight ulcerative colitis and one familial adenomatous polyposis) had undergone prior subtotal colectomy and therefore underwent restorative proctectomy with IPAA. Eleven patients underwent restorative proctocolectomy. All procedures were completed robotically. The median length of stay was 9 days (5-49). There were no unplanned admissions to intensive care and no deaths. Three patients were readmitted following hospital discharge for (i) an ileus managed conservatively, (ii) small bowel obstruction managed conservatively and (iii) small bowel obstruction due to constriction at the stoma site necessitating surgery. There were two additional reoperations both for drain complications, one for drain removal and one for drain erosion. On mobilization of the pouch in the latter case, an anastomotic defect was observed. In total, 19/20 patients underwent RiSSA without postoperative anastomotic problems.

DISCUSSION

RiSSA offers a safe and feasible alternative technique to other minimally invasive approaches with low rates of anastomosis-related complications.

Aspects Towards the Anastomotic Healing in Crohn’s Disease: Clinical Approach and Current Gaps in Research

Anastomotic leakage is a major complication in gastrointestinal and colorectal surgery and its occurrence increases morbidity and mortality. Its incidence is even higher in Crohn’s disease surgeries. Several authors have identified factors involved in the pathophysiology of anastomotic leak in the literature, aiming to reduce its occurrence and, therefore, improve its surgical treatment. Surgical technique is the most discussed topic in studies on guiding the performance of side-to-side stapled anastomosis. Preoperative nutritional therapy also has been shown to reduce the risk of anastomotic leakage. Other factors remain controversial – immunomodulator use and biologic therapy, antibiotics, and gut microbiota – with studies showing a reduction in the risk of complication while other studies show no correlation. Although mesenteric adipose tissue has been related to disease recurrence, there is no evidence in the literature that it is related to a higher risk of anastomotic leakage. Further exploration on this topic is necessary, including prospective research, to support the development of techniques to prevent anastomotic leakage, in this way benefiting the inflammatory bowel disease patients who have to undergo a surgical procedure.

Artificial intelligence: Emerging player in the diagnosis and treatment of digestive disease

Given the breakthroughs in key technologies, such as image recognition, deep learning and neural networks, artificial intelligence (AI) continues to be increasingly developed, leading to closer and deeper integration with an increasingly data-, knowledge- and brain labor-intensive medical industry. As society continues to advance and individuals become more aware of their health needs, the problems associated with the aging of the population are receiving increasing attention, and there is an urgent demand for improving medical technology, prolonging human life and enhancing health. Digestive system diseases are the most common clinical diseases and are characterized by complex clinical manifestations and a general lack of obvious symptoms in the early stage. Such diseases are very difficult to diagnose and treat. In recent years, the incidence of diseases of the digestive system has increased. As AI applications in the field of health care continue to be developed, AI has begun playing an important role in the diagnosis and treatment of diseases of the digestive system. In this paper, the application of AI in assisted diagnosis and the application and prospects of AI in malignant and benign digestive system diseases are reviewed.

Mesenchymal stem cells-derived extracellular vesicles containing miR-378a-3p inhibit the occurrence of inflammatory bowel disease by targeting GATA2

This study sought to determine whether mesenchymal stem cells‐derived extracellular vesicles (MSCs‐EVs) carrying microRNA‐378a‐3p (miR‐378a‐3p) could affect the pathogenesis of inflammatory bowel disease (IBD) by regulating the GATA‐binding protein 2 (GATA2)/aquaporin‐4 (AQP4)/peroxisome proliferator‐activated receptor α (PPAR‐α) axis. Initially, colon mucosa biopsy tissues were harvested from healthy controls and patients with IBD for qRT‐PCR and immunohistochemistry analysis. EVs harvested from MSCs and lipopolysaccharide (LPS) were used to stimulate the M064 cells to establish an in vitro inflammation cell model. Besides, 2,4,6‐trinitrobenzene sulfonic acid intracolon administration was performed to establish in vivo IBD mouse models. After loss‐ and gain‐of‐function assays, the regulatory role of MSCs‐derived EVs loaded with manipulated miR‐378a‐3p in IBD in relation to GATA2/AQP4/PPAR‐α were explored. Upregulation of GATA2 was identified in the colon tissue of IBD patients. GATA2, which was a target gene of miR‐378a‐3p, transcriptionally upregulated AQP4. After silencing of GATA2, LPS‐induced apoptosis of M064 cells was reduced by the downregulation of AQP4. Decreased AQP4 contributed to PPAR‐α pathway inactivation and weakened the LPS‐induced apoptosis of M064 cells. MSCs‐EVs delivering miR‐378a‐3p suppressed the GATA2/AQP4/PPAR‐α pathway, which reduced LPS‐induced apoptosis of M064 cells and the occurrence of IBD in mice. Altogether, the current study illustrated that MSCs‐EVs transfer miR‐378a‐3p to reduce the GATA2 expression, which downregulates AQP4 to block the PPAR‐α signalling pathway, thus suppressing the occurrence of IBD.

microRNA-15b-5p encapsulated by M2 macrophage-derived extracellular vesicles promotes gastric cancer metastasis by targeting BRMS1 and suppressing DAPK1 transcription

BACKGROUND

Extracellular vesicles (EVs) derived from tumor-associated macrophages are implicated in the progression and metastasis of gastric cancer (GC) via the transfer of molecular cargo RNAs. We aimed to decipher the impact of microRNA (miR)-15b-5p transferred by M2 macrophage-derived EVs in the metastasis of GC.

METHODS

Expression of miR-15b-5p was assessed and the downstream genes of miR-15b-5p were analyzed. GC cells were subjected to gain- and loss-of function experiments for miR-15b-5p, BRMS1, and DAPK1. M2 macrophage-derived EVs were extracted, identified, and subjected to co-culture with GC cells and their biological behaviors were analyzed. A lung metastasis model in nude mice was established to determine the effects of miR-15b-5p on tumor metastasis in vivo.

RESULTS

miR-15b-5p was upregulated in GC tissues and cells as well as in M2 macrophage-derived EVs. miR-15b-5p promoted the proliferative and invasive potentials, and epithelial-mesenchymal transition (EMT) of GC cells. M2 macrophage-derived EVs could transfer miR-15b-5p into GC cells where it targeted BRMS1 by binding to its 3'UTR. BRMS1 was enriched in the DAPK1 promoter region and promoted its transcription, thereby arresting the proliferative and invasive potentials, and EMT of GC cells. In vivo experiments demonstrated that orthotopic implantation of miR-15b-5p overexpressing GC cells in nude mice displayed led to enhanced tumor metastasis by inhibiting the BRMS1/DAPK1 axis.

CONCLUSIONS

Overall, miR-15b-5p delivered by M2 macrophage-derived EVs constitutes a molecular mechanism implicated in the metastasis of GC, and may thus be considered as a novel therapeutic target for its treatment.